Summary

A 70-year-old man presented with severe right testicular pain radiating to the groin, and was admitted under the urologist.
A kidney, ureter and bladder CT scan showed a leaking abdominal aortic aneurysm (AAA). The presentation, nature and management
of a leaking AAA are reviewed.

BACKGROUND

Ruptured abdominal aortic aneurysm ((R)AAA) is a life-threatening condition with a mortality rate approaching 90%1 with greater than 44% prehospital mortality. Of those that make it to the hospital, emergency surgery still has a mortality
rate of 50%.1 Ruptured AAA can prove difficult to diagnose, especially when not suspected. The classical presentation includes a pulsatile
mass in the abdomen, back pain and episodes of haemodynamic instability. Other common presentations include loin pain and
mass in the abdomen.2 We report a rare case of ruptured AAA where the patient presented with right testicular pain and diagnosis was only made
on kidney, ureter and bladder CT scan.

CASE PRESENTATION

A 70-year-old man was referred to the urologist with a diagnosis of right testicular torsion. He presented after midnight
with sudden onset severe right-sided testicular pain. The pain started suddenly, sharp in nature, radiating to the groin.
There was no history of trauma and he denied any urinary symptoms. His past medical history included asbestosis, hypertension
and anxiety. He had a vasectomy in 1976. Medications included bisoprolol, doxazocin and antidepressants. He was a smoker of
one packet of cigarettes per day, with minimal alcohol consumption, and lived with his wife.

On examination he was afebrile, pulse 80 beats/min, blood pressure 120/70 with a haemoglobin level of 14.2 mg/dl on admission.
The patient had a Body Mass Index (BMI) of 40. Abdominal examination did not reveal any obvious mass; groin examination revealed
a very tender swollen right testicle and a normal left side. During the period of examination the patient developed a right-sided
loin pain and was unable to lie still. A diagnosis of ureteric colic was suspected and a kidney, ureter and bladder CT scan
arranged. At this stage the patient was haemodynamically stable. A CT scan showed a leaking AAA (fig 1).

INVESTIGATIONS

TREATMENT

OUTCOME AND FOLLOW-UP

A vascular surgeon was contacted and the patient taken to theatre. In theatre, a posterior leak from a 6.5 cm ruptured infrarenal
fusiform abdominal aortic aneurysm was confirmed. The AAA was repaired successfully and the patient made a good recovery.
The patient spent 48 h in the intensive care unit and was discharged home after 2 weeks in hospital

DISCUSSION

An aortic aneurysm is a thin, weakened section of the wall of the aorta that bulges outward; rupture of the aneurysm is a
life-threatening condition. Many patients do not make it to the hospital. Of those that do reach the hospital, prompt diagnosis
and emergency surgery is the only option. Delay in diagnosis often contributes to the already high mortality rate. Ruptured
AAA can present or mimic a variety of cases, such as renal colic, diverticulitis, acute myocardial infarction, backache, sepsis,1 buttock pain,3 appendicitis,4 strangulated inguinal hernia2 and testicular pain.5

Establishing a diagnosis of RAAA requires a high index of suspicion, especially in older patients with risk factors for cardiovascular
disease. These include smoking, diabetes, hypertension and hypercholesterolaemia.

The classical presentation includes an older man with a history of collapse associated with abdominal, flank or back pain.
Examination reveals an expansile, pulsatile mass with haemodynamic instability. In a patient who is deemed fit for aneurysm
repair, the management is immediate resuscitation and an exploratory laparotomy with aneurysmal repair. In those who present
with more subtle signs, difficult clinical examination (due to obesity) or atypical presentations, a contrast CT scan should
be performed if the patient is stable. An ultrasound scan is safer and quicker to perform, but is very operator dependant
and can be difficult in a patient who is obese. Additionally, it usually only confirms the presence of an aneurysm but often
cannot rule out a leak. In general, there should be a low threshold for imaging in an older haemodynamically stable patient
with suggestive symptoms and signs to exclude a ruptured aneurysm.

Ruptured AAA presenting with acute testicular pain is extremely rare. There are less than 10 cases reported in the literature.
Isolated sudden onset right testicular pain is even more rare. The aetiology behind the symptom is unclear. It is thought
that the developing expansion, prior to rupture, or the developing haematoma around the visceral nerves from the testes in
the lumbar region is responsible for this symptom.5 Compression of the ilioinguinal nerve or the genitofemoral nerve as it courses through the psoas muscle has been suggested
as an explanation for the testicular pain.6

LEARNING POINTS

Not all ruptured abdominal aortic aneurysm (RAAA) presents with the classical history of abdominal pain, back pain and a tender
pulsatile expansile mass on examination.

Always have high index of suspicion, especially in older patients with positive risk factors for cardiovascular disease such
as hypertension, diabetes and hypercholesterolaemia.

It is important to be aware of atypical presentation of RAAA.

Early vascular surgeon consultation in cases of suspicious presentation could be life saving.